Provider Demographics
NPI:1346078656
Name:MOMBA HOME CARE IDAHO, LLC
Entity type:Organization
Organization Name:MOMBA HOME CARE IDAHO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ELIEZER
Authorized Official - Middle Name:
Authorized Official - Last Name:AVTZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-902-7022
Mailing Address - Street 1:5565 GLENRIDGE CONNECTOR STE 500
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4796
Mailing Address - Country:US
Mailing Address - Phone:800-553-3495
Mailing Address - Fax:
Practice Address - Street 1:950 W BANNOCK ST STE 1100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6140
Practice Address - Country:US
Practice Address - Phone:800-553-3495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-26
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care